When a practitioner does not document an exact diagnosis, outpatient coding rules require that unclear diagnosis be coded using the ________ that led the patient to seek care, until an absolute diagnosis is made.
Fill in the blank(s) with the appropriate word(s).
symptoms
If a term such as probable, suspected, likely, questionable, possible, or rule out is used in the documentation, the diagnosis is uncertain. The symptoms should be coded until an absolute diagnosis is made.
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